Certified Need for Care

What are the requirements?

Criteria for home care admission

  • A physician must certify that a patient is eligible for Medicare home health services according to the Code of Federal Regulations at 42 CFR 424.22(a)(1)(i)-(v).
  • The physician who establishes the home health Plan of Care (POC) must sign and date the certification (approved practitioners are: MD, DO, DPM).

The Centers for Medicare & Medicaid Services (CMS) does not require a specific form or format for the certification as long as a Medicare-enrolled physician certifies that these five requirements, outlined at 42 CFR Section 424.22(a)(1), are met:

  1. The patient needs intermittent skilled nursing (SN) care, physical therapy (PT), and/or speech-language pathology (SLP) services
    • Occupational Therapy (OT), Social Work (MSW), Home Health Aide (HHA) services cannot “stand alone”, must also have a PT, RN, or SLP service(s)
  2. The patient is confined to the home (that is, homebound)
  3. A home health POC has been established and will be periodically reviewed by a physician
  4. Services will be furnished while the individual was or is under the care of a physician and
  5. A face-to-face encounter:
    1. Patient must have a face-to-face no more than 90 days prior to the home health start-of-care date or within 30 days of the start of the home health care
    2. Was related to the primary reason the patient requires home health services and
    3. Was performed by a physician or allowed NP/PA

Information on the Face-to-Face must include:

  • Date of encounter
  • Reason for encounter
    • The face-to-face visit must be related to the need for home care and may be carried out by Nurse practitioner/Physician Assistant, that is supervised by a physician. However, only the physician can order home care.
  • Brief statement of what is being ordered
  • Clinical statement (backed by evidence in the Medical Record) to support home care order
  • Reason for homebound function
  • Signature of Face-to-face must be a physician/NP/PA.

Generally, the Start of Care (SOC) will be initiated within 48 hours of the referral unless otherwise ordered. If the patient is not admitted, the agency will notify the referral source.

The physician will receive orders that will indicate how many times a week the patient will see a clinician and what the clinician will be doing in the home.